Do's and dont's of er.


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what to do and what not to do in emergency set up .This booklet is very helpful for young doctors and internee

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Do's and dont's of er.

  1. 1.      BY      DR  SHAHID  BASHIR  CHADHARY  ED  SPECIALIST          March  2012       1  
  2. 2.                                                                                  I  N  D  E  X  NO                            TOPIC   PAGE  NO.  1   Abscess   1  2   Anal  Fissure   2  3   Ankle  Sprain   3  4   Black  Eye   4  5   Bites   5  6   Bleeding  after  Dental  Surgery   8  7   Blunt  Scrotal  Trauma   9  8   Broken  Toe   10  9   Rib  Fracture   11  10   Bruises   13  11   Cellulitis   14  12   Collar  Bone  Fracture   16  13   Carpal  Tunnel   17  14   Cystitis   18  15   Digital  Block   19  16   Epididymitis   21  17   Finger  Dislocation   22  18   Finger  tip  Dressing   23  19   Finger  Tip  Avulsion   24  20   Fish  Hook  Removal   25  21   Foreign  Body  Beneath  Nail   26  22   Ganglion  Cyst   27  23   Minor  Implant  Injuries   28  24   Impetigo   29  25   Jaw  Dislocation   30  26   Low  Back  Pain   31  27   Minor  Head  Trauma   33  28   Muscle  Strain  and  Tears   35  29   Nail  Root  Dislocation   35  30   Nail  Bed  Laceration   37  31   Neck  Strain   38  32   Needle  in  Foot   39  33   Paronychia   41     2  
  3. 3. 33   Pencil  Point  Puncture   43  34   Periorbital  and  Conjuctival  edema   44  35   Pelvic  Inflammatory  Disease   45  36   Pinworm  or  Threadworm   46  37   Plantaris  Tendon  Rupture   47  38   Polymyalgia  Rheumatica   48  39   Rhus  contact  Dermatitis  (Poison  IVY,Oak,Sumac)   49  40   Prostitis   50  41   Pulpitis   51  42   Puncture  wound   52  43   Pyelonephritis  (Upper  urinary  Tract  Infection)   53  44   Rabies  Prophylaxis   55  45   Rectal  Foreign  Body   56  46   Removal  of  Dislocated  Contact  lens   58  47   Ring  Removal   60  48   Ruptured  Ear  Drum     61  49   Saturday  night  Palsy   62  50   Scabies   63  51   Seizure   65  52   Serous  otitis  Media   67  53   Shingles  (Herpes  Zoster)   69  54   Shoulder  Dislocation   70  55   Shoulder  Separationn  (Acromio-­‐Clavicular  Joint)   72  56   Sinusitis   73  57   Sore  Throat   76  58   Split  Ear  Lobes   79  59   Streakhouse  Syndrome   79  60   Subconjuctival  Hemorrhage   82  61   Subcutaneous  Foreign  Body   83  62   Subungeal  Ecchymosis   85  63   Subungeal  Hematoma   85  64   Subburn   87  65   Swallowed  Foreign  Body   88  66   Tailbone  Fracture  (Coccyx  Fracture)   89  67   Tear  Gas  Expoure   90  68   Tension  Headache   91  69   Tetanus  Prophylaxis   93     3  
  4. 4. 70   Thrush   94  71   Tinea   95  72   Tempromandibular  Joint   96  73   Tooth  Trauma   97  74   Upper  Respiratory  Tract  Infection   98  75   Urinary  Retention   100  76   Vaginal  Bleeding   101  77   Vaginitis   105  78   Vasovagal  Syncope   106  79   Vertigo   107  80   Weakness   109  81   Wry  Neck  (Torticollis)   111  82   Zipper  Caught  on  Penis  or  Chin   113    This   booklet   is   very   helpful   for   new   ED   Physicians   while  treating  the  patients,  and  can  avoid  those  steps  that  can  involve  them  in  medicolegal  problems.  The   material   in   this   booklet   is   taken   from   different  surgical  manuals  and  reference   books,  also  included  my  practical   experience   of   work   in   the   emergency  department  in  tertiary  referral  hospital.  I  need  your  opinion  and  suggestions.  DR  SHAHID  BASHIR  CHAUDHARY  MBBS  DTCD,FCCS     4  
  5. 5. ABSCESS:    WHAT  TO  DO:   1. Simply  snip  open  the  cutaneous  roof  with  fine  scissor  or  an  inverted  #11   blade.   2. When  the  location  of  an  abscess  cavity  is  uncertain,  attempt  to  aspirate  it   with  a  #18  gauge  needle  after  preparing  the  area  with  Povidine  –iodine.   3. Anesthetize   the   area   with   regional   field   block   and   give   additional   anesthesia  like  I/V  paracetamol  1  gm.   4. Make  the  incision  at  the  most  dependent  area.   5. In   large   abscesses   insert   a   hemostat   in   to   the   cavity   to   break   up   any   loculated   collection   of   pus   and   irrigate   with   normal   saline,   put   packing   and    do  dressing,   6. The  patient  should  be  instructed  to  use  intermittent  warm  water  soaks.   7. Ask  for  dressing  after  two  days.   8. Discharge  the  patient  with  antibiotic  cover.  WHAT  NOT  TO  DO:   a. Do  not  incise  an  abscess  that  lies  close  to  major  vessel,  such  as  in   axilla,  groin  or  anticubital  space.   b. Do   not   treat   deep   infections   of   the   hands   as   simple   cutaneous   abscesses.   c. Routine  culture  is  not  indicated.         5  
  6. 6. ANAL  FISSURE  Patient   complains   of   painful   rectal   bleeding   and   sometimes   constipation,   the  pain   occurs   with   and   immediately   after   defecation,   the   patient   is   relatively  comfortable   between   bowel   movements.   bleeding   with   defecation   is   usually  slight,   only   staining   the   toilet   tissue.   Mucus   discharge   may   increase   perineal  moisture  and  cause  itching.  Examination  of  anus  reveals  a  radial  tear  or  ulceration  of  the  posterior  midline  95%of  the  time.  WHAT  TO  DO:   1. Provide  topical  anesthesia  with  lidocain.   2. Advise   the   patient   to   take   soft   diet   and   use   a   glycerin   suppository   twice   daily  to  maintain  lubrication  of  the  anal  canal.   3. Instruct   the   patient   to   use   warm,   soothing   sitz   baths   after   each   painful   bowel  movement.   4. Prescribe  analgesia  if  needed.   5. Inform   the   patient   that   an   acute   superficial   fissure   will   take   about   one   month  to  heal   6. He  /she  should  follow  up  in  OPD.  WHAT  NOT  TO  DO:       a. Do   not   assume   that   a   lesion   located   outside   the   anterior-­‐posterior   midline      saggital  plane  of  anus  is  an  anal  fissure     b. Do  not  confuse  a  sentinel  pile  with  a  heamorrhoidal  vein.     6  
  7. 7. ANKLE  SPRAIN:  The  patient  inverted  the  foot  and  either  came      immediately  or  a  day  later  with  pain,   swelling   and   inability   to   walk,   there   is   tenderness   to   palpation   of   the  anterior  talofibularr  ligament.  WHAT  TO  DO:   1. Elevate   the   foot   and   apply   ice   for   15   minutes/hr   to   treat   the   reactive   inflammation   2. Palpate   the   prominence   on   the   lateral   foot   to   check   the   avulsion   of   peroneus  brevious   3. Palpate  the  fibula  on  the  lateral  leg  up  to  the  knee,  where  spiral  fracture   can  propagate   4. If   there   is   tenderness   and   patient   cannot   take   four   steps   in   the   ED,   obtain   x-­‐rays  to  rule  out  a  fracture.   5. Immobilize  the  ankle  in  a  stirrup.   6. Anti-­‐inflammatory  analgesics.   7. Follow  up  to  ortho  OPD/ED.  WHAT  NOT  TO  DO:   a. Don’t  rule  a  fracture  based  on  a  negative  x-­‐rays.   b. Don’t   overlook   fractures   of   the   tarsal   navicular,   talus   or   os   trigonum,  all  visible  on  the  ankle  view.         7  
  8. 8. BLACK  EYE  The   patient   has   received   blunt   trauma   to   the   eye,   most   often   from   a   fist,   a   fall,   or  a   car   accident   Family   and   friends   are   more   concerned   than   the   patient   about   the  appearance  of  the  eye.  There   may   be   associated   subconjuctival   hemorrhage,   but   the   remainder   of   the  eye  examination  should  be  negative.    WHAT  TO  DO:   1. Clarify  as  well  as  possible  the  specific  mechanism  of  injury.   2. Perform   a   complete   eye   exam   to   rule   out   a   retinal   detachment   or   dislocated  lens.   3. Fluorescein  stain  to  rule  out  corneal  abrasion.   4. Test  extra  ocular  eye  movements;  look  especially  for  diplopia  on  upward   gaze.   5. Check  sensations  over  the  infra  orbital  nerve  distribution.   6. Symmetrically  palpate  the  supra  and  infra  orbital  rims  as  well  as  zygoma.   7. If   there   is   any   suspicion   of   any   underlying   fracture,   obtain   x-­‐rays   of   the   orbit.   8. If  significant  injury  is  discovered,  then  consult  with  an  ophthalmologist.   9. CT   scan   is   more   sensitive   and   can   visualize   subtle   fractures   of   the   orbit   and  small  amount  of  air.   10. When   there   is   significant   injury   ,   reassure   the   patient   that   the   swelling   will  subside  with  in  12-­‐24  hrs     8  
  9. 9. 11. Give  inj.  paracetamol  1gm  i/v.  or  oral  paracetamol  1  gm.   12. Instruct  the  patient  to  follow  up  in  ophthalmology  clinic  WHAT  NOT  TO  DO:   a. Don’t  get  unnecessary  radiograph.   b. Minor   injuries   with   normal   eye   exams   and   no   palpable   deformities  do  not  require  X-­‐rays.   c. Do   not   brush   off   bilateral   deep   peri   orbital   ecchymosis   (raccoon   eye),   especially   if   caused   by   head   trauma   remote   to   the  eye.    BITES  A  single  bite  may  contain  various  types  of  injury,  including  underlying  fractures  and  tendon  and  nerve  injuries,  not  all  of  which  are  immediately  WHAT  TO  DO:   1. Obtain  a  complete  history  including,  the  type  of  animal  that  bit,  whether   or   not   the   attack   was   provoked,   what   time   the   injury   occurred,   the   current   health   status   and   vaccination   record   of   the   animal   has   been   captured   and   is   being   held   for   observation,   report   the   bite   to   police   or   appropriate  local  authorizes.   2. Assess   the   wound   for   any   damage   to   deep   structures,   any   need   for   surgical  consultation  and  risk  of  infection.   3. Look  for  bone  and  joint  involvement  and  if  present.     9  
  10. 10. 4. Obtain   appropriate   imaging   studies   (dog   bites   have   caused   open   depressed  fractures  in  small  children).   5. Examine   for   nerve   and   tendon   injury   and   be   aware   that   crush   and   puncture   wounds   as   well   as   bites   on   the   hands,   wrist,   and   feet,   are   at   higher   risk   for   development   of   infection   and   significant   complications   such  as  tenosynovitis,  septic  joints,  osteomylitis  and  sepsis.   6. If  tissue  damage  is  higher  then  take  opinion  of  surgery  and  orthopedic.   7. For   crush   wounds   and   contusions,   elevate   above   the   heart   and   apply   cold   packs.   8. If  the  wound  requires  debridement,  or  will  be  painful  to  clean  or  irrigate,   then  anesthetize  the  area.   9. If  there  is  already  sign  of  infection,  obtain  aerobic  and  anaerobic  cultures   of  pus.   10. Irrigate  the  wound  with  antiseptic  (10%povidine-­‐iodine  solution,  dilated   1:10   in   normal   saline)   and   sharply   debride   any   debris   and   non   –viable   tissue.   11. Irrigate   the   wound,   using   a   20ml   syringe,   a   19   gauge   needle   or   an   irrigation  shield,  and  at  least  200ml  of  sterile  saline.   12. For   animal   bite   wounds   that   are   clean,   uninfected   lacerations   located   anywhere  other  than  the  hand  or  foot.  You  may  suture.   13. If  the  wound  is  infected  when  first  seen  .plan  either  a  delayed  repair  after   three  to  five  days  of  saline  dressings  or  secondary  wound  healing  with  out   closure.   14. Prescribe  antibiotics  for  seven  days.   15. Severe  infection  requires  hospitalization.     10  
  11. 11. 16. With   human   bites,   animal   bites   that   are   punctured   or   located   on   he   hand,   wrist   or   foot,   or   bite   more   than   12   hours   old   ,in   most   cases,   you   should   leave  the  wounds  open  and  apply  a  light  dressing  .   17. Wounds   should   also   be   left   open   on   debilitated   and   patients   with   diabetes,   alcoholism,   chronic   steroid   use,   organ   transplants,   vascular   insufficiency,   spleenectomy,   HIV   or   other   immnunocompromised   conditions,   18. Start  prophylactic  antibiotics  in  the  ED  on  these  wounds  and  in  patients   with  artificial  or  damaged  heart  valves  and  implanted  prosthetic  devices,   19. If   the   patient   has   had   no   tetanus   toxoid   in   the   past   5-­‐10   years,   provide   prophylaxis.   20. Start  rapid  rabies  vaccination:     i. first  day  (0)   ii. third  day(3)   iii. seventh  day(7)   iv. Fourteenth  (14)   v. Twenty-­‐eighth  (28)   21. Provide   hepatitis   prophylaxis   for   patients   who   have   been   bitten   by   known   carriers   of   hepatitis   B.   Administer   hepatitis   B   immunoglobulin   0.06ML/kg   i/m   at   the   time   of   injury   and   schedule   a   second   dose   in   30   days.   22. Follow  standard  guidelines  applicable  to  contaminated  needle  sticks.   23. Minimize  edema  of  hand  wound  by  splitting  and  elevation.     11  
  12. 12. 24. Have  patient  returns  for  a  wound  check  in  two  days  or  sooner  if  there  is   any  sign  of  infections.   25. Explain   the   potential   for   serious   complication   such   as   septic   arthritis,   swollen   immobile,   tender   along   the   flexor   surface   painful   on   passive   extension  that  will  require  specially  consultation.  WHAT  NOT  TO  DO:   a. Do  not  overlook  a  puncture  wound.   b. Do   not   suture   debris,   non   –viable   tissue   or   a   bacteria   inoculation  into  a  wound.   c. Do   not   use   buried   absorbable   suture,   which   act   as   foreign   body   and   cause   a   reactive   inflammation   for   about   a   month   and   increase  the  risk  of  infection.   d. Do  not  routinely  suture  human  bites.    BLEEDING  AFTER  DENTAL  SURGRY  The   patient   had   an   extraction   or   other   dental   surgery   performed   earlier   in   the  day,  now  ha  excessive  bleeding  at  the  site  and  can  not  reach  his/her  dentist.  WHAT  TO  DO:   1. Ask  what  procedure  was  done     2. Inquire  about  antiplatelet  drugs,  like  aspirin.   3. H/O  previous  experience  of  bleeding     12  
  13. 13. 4. Use   suction   and   saline   irrigation,   clear   any   packing   and   clot   from   the   bleeding  site.   5. Roll  a  2x2”  gauze  pad,  insert  it  over  the  bleeding  site.   6. If  the  site  is  still  bleeding  after  20  minutes  of  gauze  pressure  ,inject  local   anesthetic,   7. If  this  does  not  stop  the  bleeding.  Pack  the  bleeding  site  with  Gel  foam.   8. An  arterial  bleeding  requires  ligation  with  figure  eight  stitch.   9. When  the  bleeding  stops,  remove  the  overlying  gauze.   10. Arrange  the  follow  up  for  dentist   WHAT  DO  NOT  DO:   a. Don’t  do  routine  lab  tests.   b. Don’t  use  tea  bags  as  a  gauze    BLUNT  SCROTAL  TRAUMA  Blunt   injuries   to   the   scrotum   usually   occur   in   patients   less   than   50   yrs.   Of   age   as  a   result   of   an   athletic   injury,   a   straddle   injury,   an   automobile   or   industrial  accident,   or   as   an   assault.   Patient   presents   with   various   degrees   of   pain,  ecchymosis  and  swelling.  WHAT  TO  DO:   1. Get  a  clear  history  of  the  exact  mechanism  of  the  trauma  and  the  point  of   maximum  impact.   2. Determine  if  there  was  any  bloody  penile  discharge  or  hematuria.b     13  
  14. 14. 3. Gently  examine  the  external  genitalia  and  give  analgesia  according  to  pain   scale.   4. If   scrotal   swelling   is   not   too   severe,   try   to   palpate   and   assess   the   intrascrotal  anatomy.   5. Obtain  urinalysis   6. Do  digital  examination  of  the  prostate  and  obtain  urologic  consultation.   7. When   urologic   intervention   is   not   required,   provide   analgesia,   bed   rest,   scrotal  support,  a  cold  pack  and  urologic  follow  up.  WHAT  NOT  TO  DO:   a. Don’t   miss   testicular   torsion   which   can   be   associated   with   blunt   trauma.   b. Don’t  miss  the  rare  traumatic  testicular  dislocation  that  results  in   an  “empty  scrotum”.      BROKEN  TOE  The   patient   has   stubbed,   hyper   flexed,   hyper   extended,   hyper   abducted   or  dropped   a   weight   upon   a   toe.   Patients   present   with   a   pain,   ecchymosis,   and  decreased   range   of   motion   and   point   tenderness   and   there   may   or   may   not   be  any  deformity.  WHAT  TO  DO:   1. Examine  the  toe,  particularly  for  lacerations.   2. Relieve  the  pain  by  anti-­‐inflammatory  analgesics.   3. Take  x-­‐rays  to  look  fracture  entering  the  joint  space.     14  
  15. 15. 4. Displaced   or   angulated   phalangeal   fracture   must   be   reduced   with   linear   traction  after  digital  block.   5. Splint   the   broken   toe   by   tapping   it   to   an   adjacent   non   effected   toe   ,   padding  between  toes  with  gauze  and  using  half  inch  sticking  plaster.   6. Advise   the   patient   to   be   immobilized   by   using   clutches   or   wearing   hard   sole  shoe  and  elevate  the  toe  at  sleeping  time  and  put  ice  bar  on  the  pad.   7. Inform   the   patient   that   he/she   must   keep   the   padding   dry   between   toe   while  they  are  tapped  together  otherwise  skin  will  mace  and  break  down.   8. If  the  fracture  is  not  of  phalanx,  but  of  the  metatarsal,  construct  a  pad  for   the  sole  with  space  cut  to  the  foot.   9. Arrange  a  follow  up  for  the  orthopedic  OPD  with  in  one  week  WHAT  NOT  TO  DO:   a. Do   not   tape   together   with   out   keeping   pad   between   toes   wetness  and  Friction  will  maceration  will     b. Do   not   let   the   patient   overdo   the   ice,   which   should   not   be   applied  directly.   c. Don’t   overlook   the   possibility   of   acute   gouty   arthritis,   which   sometimes  follow  minor  trauma.    RIIB  RFACTURE:  It  is  due  falling  down  on  the  side  of  the  chest,  initial  chest  pain  may  subside  but  over  the  few  hours  or  days  pain  increases  and  patient  visits  the  ED  for  chest  pain,     15  
  16. 16. there   is   point   tenderness   at   the   site   of   injury   and   occasionally   bony   crepitance  can  be  felt.  WHAT  TO  DO:   1. Examine  the  patient  for  possible  associated  injuries     2. Relieve   the   pain   and   compress   the   rib   medially   if   anterior   or   posterior   fracture  is  suspected,   3. Compress  the  rib  anterior  /posterior  if  the  fracture  is  suspected  laterally.   4. When   the   pain   occurs   at   the   suspected   fracture   site   with   indirect   stress,   this  is  clinical  evidence  of  fracture  and  document.   5. Obtain  a  history  of  chronic  pulmonary  problems  or  heavy  smoking.   6. Send   the   patient   for   PA/LAT   view   of   x-­‐rays   chest   to   rule   out   pneumothorax,  hemothorax  or  evidence  of  pulmonary  contusion.   7. If   there   is   no   evidence   of   underlying   injury   and   there   is   clinical   and   radiological   evidence   of   rib   fracture,   call   surgical   team   or   arrange   appointment  for  Surgical  OPD  with  in  48  hours  and  discharge  the  patient   by  advising  potent  oral  analgesics.   8. Instruct   the   patient   on   the   intermittent   use   of   an   elastic   rib   belt   if   it   reduces  pain.   9. Ask  the  patient  about  the  importance  of  deep  breathing  and  coughing  to   help  prevent  pneumonia.   10. Advise  the  patient  rest  for  one  week  according  the  organization  policy.   11.  If  the  patient  is  compromised  and  have  cardiac  or  associated  respiratory   disease  and  the  patient  is  old  then  hospitalization  is  required.       16  
  17. 17. WHAT  NOT  TO  DO:   a. Don’t  confuse  simple  rib  fracture  with  massive  blunt  trauma  to   the  chest.   b. Do  not  tape  ribs  or  use  continuous  strapping.   c. Do  not  assume  that  there  is  no  fracture  because  the  x-­‐rays  are   negative,   Rib   fractures   is   often   not   apparent   on   x-­‐rays,   especially  when  they  occur  on  cartilaginous  portion  of  the  rib.    BRUISES  The  patient  has  fallen  on  or  thrown  against  the  object  has  been  struck  at  a  site  with  the  point  of  tenderness  and  swelling.  Pain,  ecchymosis  and  hematoma.  On  Physical   examination   there   is   no   loss   of   function   of   muscles   and   tendons,   no  instability   of   bones   and   ligaments   and   no   crepitus   or   tenderness   produced   by  remote  stress.  WHAT  TO  DO:   1. Take   a   thorough   history   to   ascertain   the   mechanism   of   injury   and   perform   a   complete   examination   to   document   structural   integrity   and   bony  injury   2. Do   x-­‐rays   if   you   suspect   possibility   of   bony   injury   or   foreign   body,   fractures  are  uncommon  after  a  direct  blow.   3. Explain   the   patient   that   swelling   will   be   at   peak   in   one   day   and   then   resolve  gradually.     17  
  18. 18. 4. Giving   anti-­‐inflammatory   drugs   and   prescribing   rest   of   effected   part,   immobilization,  elevation  and  ice  padding  reduce  the  swelling.   5. Explain  the  patient  late  migration  and  color  changes  of  ecchymosis.   6. A   large   intramuscular   hematoma       may   require   drainage   ororthopeadic   consultation.   7. Arrange   for   follow   up   in   surgical   OPD,   if   the   patient   returns   ED   with   increased  discomfort.  WHAT  NOT  TO  DO:   a. Do   not   apply   a   elastic   bandage   to   the   middle   of   limb   where   it   may  act  as  a  tourniquet.   b. Do   not   confuse   patient   with   instructions   for   application   of   heat   and   exercise   to   prevent   stiffness   and   atrophy,   concentrate  on  the  here  –and  –  now  therapy.  CELLULITIS  The  cardinal  sign  of  infection  (pain,  redness,  warmth,  and  swelling)  are  present.  Erysipelas   is   very   superficial   and   bright   red   with   indurate,   sharply   demarcated  borders.  Cellulitis   is   deeper,   involves   the   subcutaneous   connective   tissue   and   has  indistinctive  advancing  borders.  These  infections  are  preceded  by  minor  trauma  of  the  presence  of  foreign  body  and   are   most   common   in   those   patients   who   have   predisposing   factor   like  diabetes   mellitus,   DVT   and   lymphatic   drainage   obstruction,   they   may   be     18  
  19. 19. associated   with   an   abscess   or   they   may   have   no   clear   –cut   origin.   The   patient  may  have  tender  lymphadenopathy  proximal  to  the  site  of  infection  and  may  or  may  not  have  signs  of  systemic  toxicity  (fever,  rigor  and  listlessness).  WHAT  TO  DO:   1. Look  for  possible  source  of  infection  and  remove  it.   2. Deride   and   cleans   any   wound,   remove   any   foreign   body   or   drain   any   abscess.   3. When   the   patient   is   very   sick   and   there   is   discoloration   of   the   limb,   get   medical  consultation  and  take  all  basic  investigation  (CBC,  BIO.  Culture),   and  X-­‐rays  chest  and  limb.   4. Hospitalize  the  patient  through  surgical  team,   5. If  there  is  low  grade  fever  or  none  at  all  then  prescribe  third  generation   antibiotics  and  anti-­‐inflammatory  analgesics.   6. Instruct  the  patient  to  keep  the  infected  part  at  rest  and  elevated  and  to   use  intermittent  warm  moist  compression.   7. Advise  the  patient  to  follow  up  in  ED  with  in  24-­‐48  hour  WHAT  NOT  TO  DO:   a. Do   not   send   the   patient   home   if   there   is   suspicion   of   deep   facial   cellulites      or  the  patient  has  deep  infection  of  the  handed  even   the  patient  is  a  febrile         19  
  20. 20.  COLLAR  BONE  FRACTURE  (CLAVICLE)  The  patient  has  fallen  into  his  shoulder  or  out  stretched  arm  or  more  commonly  has  received  a  direct  blow  to  the  clavicle  and  now  present  with  the  pain  to  direct  palpation   over   the   clavicle   or   with   movement   of   arm   or   neck,   there   may   be  deformity  of  the  bone  with  the  swelling  and  ecchymosis.  An   infant   or   small   child   might   present   after   a   fall,   not   moving   arm   with   above  findings.  WHAT  TO  DO:   1. After   completing   the   musculoskeletal   examination,   evaluate   the   neurovascular  status  of  the  arm.   2. Fit  a  sling  or  clavicle  strap  that  comfortably  immobilizes  the  arm.   3. Prescribe  analgesics  like  ibuprofen  or  naproxen.   4. Obtain  x-­‐rays  to  rule  out  other  injuries  and  document  the  fracture.   5. Arrange  for  orthopedic  follow  up  in  a  week  to  evaluate  heeling  and  begin   pendulum  exercise  of  the  shoulder  by  physiotherapy  or  advise  patient  by   you.  WHAT  NOT  TO  DO:   b. Do  not  apply  figure  of  eight  dressing  or  clavicle  strap  if  this  form   of  splitting  increases  patient’s  discomfort.   c. Do   not   leave   arm   immobilized   in   a   sling   for   more   than   week   ,   this   can   result   in   loss   of   range   of   motion   or   frozen   shoulder,   therefore  instruct  patient  before  sending  home.     20  
  21. 21.  CARPAL  TUNNEL  Patient  complains  of  pain  or  “pins  and  needle”  sensation  in  the  hand.  Onset  may  have  been  abrupt  or  gradual  but  the  problem  is  most  noticeable  upon  awaking  or  after  extended  use  of  the  hand.  The  sensations  may  be  bilateral,  may  include  pain  in   the   wrist   or   forearm   and   is   usually   ascribed   to   the   entire   hand   until   specific  physical   examination   localized   it   to   the   median   nerve   distribution.   More  established   cases   might   include   weakness   of   the   thumb   and   atrophy   of   the  thenaar  eminence.  Physical   examination   localizes   paresthesia   and   decreased   sensation   to   the  median  distribution  and  motor  weakness.  WHAT  TO  DO:   1. Perform   and   document   complete   examination,   sketching   the   area   of   decreased  sensation  and  grading  the  strength  of  the  hand.   2. Hold   the   wrist   flexed   at   90-­‐degree   angle   for   60   seconds,   to   see   if   it   reproduces   symptoms,   this   is   known   as   PAHALEN’S   TEST   and   is   more   sensitive  and  more  specific.   3. Explain  the  nerve  –compression  etiology  to  the  patient   4. Call  surgical  team  or  arrange  evaluation  and  follow  up  referral.   5. Borderline  diagnosis  is  established  with  electromyography(EMG)     6. Early  surgical  intervention  is  indicated  when  there  is  pain  and  weakness.     21  
  22. 22. 7. Anti-­‐inflammatory   medication,   elevation   of   the   affected   hand,   ice,   immobilization   with   a   volar   splint   and   rest   may   all   help   to   reduce   symptoms.  WHAT  NOT  TO  DO:   a. Do   not   rule   out   thumb   weakness   just   because   the   thumb   can   touch  the  little  finger.   b. Do  not  diagnose  carpel  tunnel  syndrome  solely  on  the  basis  of  a   positive  Tinley’s  sign.    CYSTITIS  The   patient   complains   of   urinary   frequency   and   urgency,   internal   dysuria   and  supra  pubic  pain,  they  may  sometime  have  antecedent  trauma  in  females  (sexual  intercourse)  to  inoculate  the  bladder  and  there  may  be  blood  in  the  urine.    WHAT  TO  DO:   1. Take  urine  for  white  cells  and  if  possible  for  Gram  stain.   2. If   the   clinical   picture   is   clearly   that   of   an   uncomplicated   lower   UTI,   give   Ciprofloxacin  and  analgesics.  For  7days.   3. Instruct  the  patient  to  drink  plenty  of  water     4. If   there   is   external   dysuria,   vaginal   discharge,   odor,   itching   and   no   frequency  or  urgency  then  evaluate  for  vaginitis.     22  
  23. 23. 5. If   the   dysuria   is   severe   then   prescribe   Phenazopyradine   (Pyridium)   200mg   tid   for   two   days   only   to   act   as   surface   anesthetic   in   the   bladder.   warn  the  patient  that  urine  will  stain  orange.   6. Arrange  follow  up  in  urology  department.  WHAT  NOT  TO  DO:   a. Do   not   undertake   urine   culture   for   every   lower   UTI   or   recent   onset  in  non  pregnant  ,   b. Do   not   follow   the   single   dose   or   3   day   regimen   for   possible   upper  UTI.   c. Do  not  rely  upon  gross  inspection  of  urine  sample;  crystals  and   odor  usually  cause  cloudiness  usually  from  diet  or  medication.   d. Do   not   require   follow   up   visit   or   culture   therapy   unless   symptoms  persist  or  reoccur.    DIGITAL  BLOCK  It   is   necessary   to   provide   complete   anesthesia   when   treating   most   fingertip  injuries,   many   techniques   for   performing   nerve   block   have   been   described,   as  the   following   is   the   one   that   is   both   effective   and   rapid   in   onset.   This   type   of  digital  block  will  only  provide  anesthesia  distal  to  the  inter  phalangeal  joint,  but  this  is  most  often  the  site  that  demands  a  nerve  block.  WHAT  TO  DO:     23  
  24. 24. 1. Cleans   the   finger   and   paint   the   area   with   Povidine-­‐   iodine   (Betadine)   solution.   2. Using   a   27-­‐gauge   needle,   slowly   inject   1%lidocain   midway   between   the   dorsal   and   palmer   surface   of   the   finger   at   the   mid   point   of   the   middle   phalanx.   3. Inject   straight   in   along   the   side   of   the   periosteum,   then   pull   with   out   removing  the  needle  from  the  skin  and  fan  the  needle  dorsally.   4. Advance  the  needle  dorsally  and  inject  again     5. Advance   the   needle   and   inject   the   lidocain   in   the   vicinity   of   the   digital   neurovascular  bundle.   6. With   each   injection,   instill   enough   lidocain   to   produce   visible   soft   tissue   swelling.   7. Repeat  this  procedure  on  the  opposite  side  of  the  finger   8. With  painful  crush  injury  or  when  the  pain  will  be  prolonged,  substitute   bupivicain  for  lidocain.    WHAT  NOT  TO  DO:   a. Do  not  use  lidocain  with  epinephrine,  The  digital  arteries  that   can   spasm   and   provide   prolonged   anesthesia,   ischemia   of   the   fingertip  and  potentially  necrosis.         24  
  25. 25. EPIDIDYMITIS.  An  adult  male  complains  of  dull  to  severe  scrotal  pain  developing  over  a  period  of   hours   to   day   and   radiating   to   the   ipsilateral   lower   abdomen   or   flank,   there  may   be   history   of   recent   urethritis,   prostitis   or   prostectomy,   straining   with  lifting  heavy  object  or  sexual  activity  with  full  bladder.  There  may  be  fever,  nausea  or  urinary  urgency  or  frequency  .The  epididymitis,  is  tender   swollen,   warm   and   difficult   to   separate   from   the   firm,   non   tender  testicles.  Increasing  inflammation  can  extend  up  to  the  spermatic  cord  and  fill  the  entire  scrotum,  making  examination  more  difficult  as  well  as  produces  frank  prostatitis  or  cystitis.  The  rectal  exam  therefore  may  reveal  a  very  tender,  boggy  prostitis.  WHAT  TO  DO:   1. Ascertain  that  testicles  are  normal  in  position  and  perfusion.     2. Doppler   ultrasound   may   help   pick   up   a   drop   off   in   arterial   flow   from   splenic  cord  to  testicle.   3. Palpate  and  auscultate  the  scrotum  to  rule  out  hernia.   4. Prescribe   antibiotics   and   call   surgical   tem   if   the   patient   is   having   sever   pain   5. Give  strong  analgesics     6. Advise   2-­‐3   days   strict   bed   rest,   with   the   scrotum   elevated   and   urologic   follow  up.  WHAT  NOT  TO  DO:   a) Do  not  miss  testicular  torsion     25  
  26. 26. b) Don’t  wait  more  than  4  hours  other  wise  chance  of  developing   ischemia  is  present,    FINGER  DISLOCATION  The   patient   has   jammed   his   finger,   causing   hyperextension   injury   that   forces   the  middle   phalanx   dorsally   and   proximally   out   of   articulation   with   the   distal   end   of  the  proximal  phalanx.  An   obvious   deformity   will   be   seen;   there   should   be   no   sensory   or   vascular  compromise.  WHAT  TO  DO:   1. X-­‐Rays  shaft  of  finger.   2. If   the   patient   is   having   considerable   delay   and   the   orthopedic   team   is   busy  then  give  digital  block.   3. To  reduce  the  joint,  do  not  pull  on  the  fingertip,  instead,  push  the  base  of   the  middle  phalanx  distally,  using  your  thumb  until  it  slides  smoothly  into   its  natural  anatomical  position.   4. Test   the   finger   by   extending   his   finger   at   the   proximal   inter   phalangeal   joint.   5. Post   reduction   x-­‐rays   should   be   taken   “chip   fracture”   may   represent   tendon  or  ligament  avulsions.   6. Splint  in  extension  for  3-­‐4  days.   7. Inform   the   patient   that   joint   swelling   and   stiffness   may   be   present   for   months  after  the  initial  injury.     26  
  27. 27. 8. Remind  the  patient  to  keep  the  injured  finger  elevated.   9. Recommend  the  ice  application  for  next  24  hours,  and  analgesics    FINGER  TIP  DRESSING  To  provide  a  complete  non-­‐adherent  compression  dressing  for  an  injured  finger  tip,   a   first   cut   out   an   L   –shaped   segment   from   a   tip   of   polyurethane   or   oil-­‐emulsion   (Adaptec)   gauze.   Cover   the   gauze   with   antibiotic   ointment   to   provide  occlusion  and  prevent  adhesion.  WHAT  TO  DO:   1. Place  the  tip  of  the  finger  over  the  short  leg  of  the  gauze  and  then  fold  it   over  the  top  of  the  finger     2. Take  the  long  leg  of  the  gauze  and  wrap  it  around  the  tip  of  the  finger.   3. For   absorption   and   compression,   a   fluff   cotton   gauze   pad   and   apply   it   over  the  end  of  the  finger.   4. Cover  with  roller  or  tube  gauze  and  secure  with  adhesive  tape.  WHAT  NOT  TO  DO:   • Do   not   place   tight   circumferential   wraps   of   the   tape   around   the   finger,                                         27  
  28. 28. FINGER  TIP  AVULSION  Mechanism   of   injury   can   be   knife,   a   meat   slicer,   closing   door   or   spinning   fan  blades  or  turning  gears.  Depending  upon  the  angle  of  amputation,  varying  degree  of  tissue  loss  will  occur  from  the  volar  pad,  or  finger  tip.  WHAT  TO  DO:   1. X-­‐ray  of  the  crush  injury  caused  by  high  speed  mechanical  instrument.   2. Consider  tetanus  prophylaxis.   3. Perform  a  digital  block  to  obtain  complete  anesthesia.   4. Thoroughly  debride  and  irrigate  the  wound.   5. When   active   bleeding   is   present   ,   provide   a   bloodless   field   by   wrapping   the  finger  from  the  tip  proximally.   6. On   a   less   than   one   square   centimeter   full   thickness   tissue   loss   ,   apply   a   simple  non  adherent  dressing  with  gentle  compression.   7. Where  there  is  greater  than  one  square  centimeter  of  full  thickness  skin   loss  there  are  three  options  that  may  be  followed.   i. Simply   apply   the   same   non   adherent   dressing   used   for   smaller    wound   ii. Call   the   surgical   team,   if   the   avulsed   piece   of   tissue   is   available  to  convert  it  into  modified  full  thickness  graft  and   suture  it  in  place.   iii. With   the   large   area   of   tissue   loss   that   has   thoughrly   cleaned,  debrided  and  where  the  avulsed  portion  has  been   lost  or  destroyed,  consider  a  thin  split  –thickness  skin  graft   on  the  site.     28  
  29. 29. 8. In  infants  and  young  children,  finger  tip  amputation  can  be  sutured  back   on  in  their  place  as  a  composite  graft,   9. When   the   loss   of   soft   tissue   has   been   sufficient   to   expose   bone,   simple   grafting   will   be   unsuccessful;   therefore   plastic   surgery   consultation   is   required.   10. Apply  a  protective  four-­‐prong  splint  for  comfort.   11. Advise  a  course  of  antibiotics  for  3-­‐5  days  and  analgesics.    WHAT  NOT  TO  DO:   a) Do   not   apply   a   graft   directly   over   the   bone   or   over   a   devitalized  or  contaminated  bed.   b) Do  not  attempt  to  stop  wound  bleeding  by  cautery  or  ligature.    FISH  HOOK  REMOVAL  The   patient   has   been   snagged   with   a   fishhook   and   arrives   with   it   embedded   in  his  skin.  WHAT  TO  DO:   1. Cleanse  the  hook  and  puncture  wound   2. Provide  tetanus  prophylaxis   3. Give  1%  local  anesthesia.   4. For   hooks   lodged   superficially,   first   try   the   simple   “retrograde   “   technique.   Push   the   back   along   the   entrance   pathway   while   applying     29  
  30. 30. gentle  downward  pressure  in  the  shank.  if  the  hook  does  not  come  out  ,   an  18  gauge  needle  may  be  inserted  in  to  puncture  hole  and  use  miniature   scalpel  blade  .Manipulate  the  hook  in  to  position  so  you  can  cut  bands  of   connective  tissue  barb  and  release  it   5. For  more  deep  imbedded  hooks  .call  the  surgical  team    WHAT  NOT  TO  DO:   a) Do  not  try  to  remove  multiple  hooks  or  fishing  lur  .   b) Do   not   attempt   to   use   the   :string”   technique   if   the   hook   is   near   the   patient’s  eye.    FOREIGN  BODY  BENEATH  NAIL  The   patient   complains   of   paint   chip   or   silver   under   the   nail.   Often   he   has  unsuccessfully   attempted   to   remove   the   foreign   body,   which   will   be   visible  beneath  the  nail.  WHAT  TO  DO  :(Paint  Chip)   1. With   out   anesthesia,   remove   the   overlying   nail   by   shaving   it   off   with   a   #15  scalpel  blade.   2. Cleanse   remaining   debris   with   normal   saline   and   trim   the   nail   edges   smooth  with  scissors.   3. Provide   tetanus   prophylaxis   if   necessary   and   then   dress   the   area   with   antibiotics  ointment.   4. Do  the  bandage.     30  
  31. 31. WHAT  TO  DO  (SILVER)   1. If   the   patient   is   cooperative   and   can   tolerate   some   discomfort,   crave   through  the  nail  down  to  the  perimeter  of  silver  with  #11  blade  until  the   overlying  nails  falls  away.   2. For   a   more   extensive   excision   of   nail   wedge,   you   will   need   to   perform   a   digital  block.   3. Slide   small   Mayo   or   iris   scissors   between   the   nail   and   nail   bed   on   both   sides  of  the  silver  and  cut  out  the  overlying  wedge  of  nail.   4. Cleans   any   remaining   debris   with   normal   saline   and   trim   the   fingernail   until  the  corners  are  smooth.   5. Give  inj  Tetanus  toxoid.   6. Dress  with  antibiotic  ointment  and  bandage   7. Advise  to  redress  after  2  –  3  days.  WHAT  NOT  TO  DO:   a) Do   not   run   tip   of   the   scissors   into   the   nail   bed   while   sliding   it   under   the  fingernail.    GANGLION  CYST  The  patient  is  concerned  about  the  rubbery,  rounded  swelling  emerging  from  the  general   are   of   a   tendon   sheath   or   the   wrist   and   hand   .It   may   have   appeared  abruptly,   been   present   for   years,   or   fluctuated,   suddenly   resolving   and   gradually  and  returning  in  pretty  much  the  same  place,  There  is  usually  little  tenderness,  inflammation  or  interference  with  function.     31  
  32. 32. WHAT  TO  DO:   1. Under   take   a   thorough   history   and   physical   exam   of   the   hand   to   ascertain   that  everything  else  is  normal.   2. X-­‐rays  are  of  no  value  unless  there  is  some  question  of  bony  pathology.   3. Explain   the   patient   that   this   is   a   fluid   filled   cyst.   Spontaneously   arising   from  bursa  or  tendon  sheath  and  posing  no  particular  danger.   4. Treatment  option  include   i. Draining  the  contents  of  the  cyst  with  an  18gauge  needle  to  reduce   its  size   ii. Injecting  corticosteroid  i/m   5. Follow  the  wishes  of  the  patient.   6. Recurrence  chances  are  present  even  with  surgical  excision    MINOR  IMPLEMENT  INJURIES  A  sharp  metal  object  such  as  a  needle,  heavy  wire,  nail  or  fork  is  driven  into  or  through  a  patient  ‘s  extremity.  In  some  instances,  the  patient  may  arrive  with  a  large  object  attached.  WHAT  TO  DO:   1. If  implant  is  acting  like  a  lever    and  causing  pain  with  movement  ,  either   immediately   pull   the   extremity   off   the   sharp   object     or   quickly     cut   through  it    to  release  the  patient,  it  can  be  cut  with  orthopedic  cutter.     32  
  33. 33. 2. Obtain   x-­‐rays   when   pain   and   further   damage   from   a   leveraged   object   is   not  a  problem.   3. Examine  the  extremity  for  possible  neurovascular  or  tendon  injury.   4. If   surgical   debridement   is   anticipated   after   removal   of   the   object   ,   then   infiltration  of  an  anesthetic  should  be  provided  prior  to  removal.   5. Objects  with  small  barbs    such  as  crochet  needle  and  fish  spines  ,  can  be   removed   by   first   anesthetizing   the   area   and   the   applying   firm   traction   until  the  barb  is  revealed  through  puncture  wound.   6. After   removal   of   the   impaled   object   ,te   wound   should   be   appropriately     debrided  and  irrigated   7. Tetanus  toxoid  is  given     WHAT  NOT  TO  DO:   b) Do   not   send   a   patient   to   x-­‐rays   with   a   leveraged   impaled.   This   creates   further  pain  and  possible  injury  with  movement.   c) Do  not  try  to  hand  –saw  off  a  board  to  an  impaled  object.    IMPETIGO  Streptococcal   lesion   consists   of   irregular   or   somewhat   circular   red,   oozing,  erosions,   often   covered   with   a   yellow   =brown   crust.   Smaller   erythmatous  macular  or  vesicopustular  areas  may  surround  these.  Streptococcal   lesion   present   as   bullae   that   are   quickly   replaced   by   a   thin   shiny  crust  over  a  erythmatous  base.     33  
  34. 34. WHAT  TO  DO:   1. Prescribe  mupiricin  2%ointment  (Bactoban)  to  rash  TID  .for  three  days.   2. Tell  parents  of  small  children  to  clean  crust  with  warm  soapy  compresses   before  applying  the  antibiotic  ointment.   3. For  repeatedly  visiting  cases  to  ED  add  a  10  days  coarse  of  Erythromycin   or   penicillin   VK   (250mg   qid)   or   intramuscular   injection   of   benzathine   penicillin   (600,000   units   i/m   for   children   and   younger,   1.2   million   units   for  children  over  7  years).   4. For   suspected   staphylococcus   infection   use   dicloxacillin   250mg   qid   in   place  of  penicillin  or  prescribe  erythromycin  or  cefadroxil.  WHAT  NOT  TO  DO:   a) Do  not  routinely  culture  these  lesions.    JAW  DISLOCATION  The  patient’s  jaw  is  “out”  and  will  not  close,  usually  following  a  yawn  ,  or  perhaps  after  laughing  ,  a  dental  extraction  ,  jaw  trauma    or  a  dystonic  drug  reaction  .  The  patient   has   difficulty   speaking   and   may   have   severe   pain   anterior   to   the   ear.   A  depression   can   be   seen   or   felt   in   the   particular   area   and   the   jaw   may   appear  prominent.    WHAT  TO  DO:   1. If  there  was  a  no  trauma  (and  especially  if  the  patient  is  chronic     dislocator)  proceed  directly  to  attempt  reduction.     34  
  35. 35. 2. If  there  is  any  possibility  of  associated  fracture  then  take  x-­‐rays.   3. Have   the   patient   sit   on   a   low   stool,   his   back   and   head   braced   against   something   firm   –   either   against   the   wall,   facing   you,   or   with   the   back   of   his  head  braced  against  your  body,  facing  away  from  you.   4. With  gloved  hands,  wrap  your  thumbs  in  gauze,  seat  them  upon  the  lower   molars,  grasp  both  sides  of  the  mandible,  lock  your  elbows,  and  bending   from   the   waist.   Exert   slow   steady   pressure   down   and   posterior.   The   mandible  should  be  at  or  below  the  level  of  your  forearm.   5. In  bilateral  dislocation,  attempt  to  reduce  one  side  at  a  time.   6. Reassess  with  x-­‐rays.   7. After  reducing  apply  soft  collar.   8. Prescribe  analgesics   9. If   reduction   cannot   be   obtained   using   above   technique,   then   consider   admission  for  reduction  under  GA.  WHAT  NOT  TO  DO:   b) Try   not   to   get   your   thumb   bitten   when   the   jaw   snaps   back   in   to   position.   c) Do  not  put  pressure  on  oral  prosthesis  that  could  cause  them  to  break.   d) Do  not  try  to  force  the  patient’s  jaw.    LOW  BACK  PAIN  Suddenly   or   gradually   after   lifting,   bending,   or   other   movement   the   patient  develops  a  steady  pain  in  one  r  both  sides  of  the  lower  back.  At  times  this  pain     35  
  36. 36. can   be   severe   and   incapacitating.   It   usually   better   on   lying   down   ,   worse   with  movement,  and  perhaps  radiates  around  the  abdomen    or  down  the  thigh  ,  but  no  farther.  WHAT  TO  DO:   1. Perform   a   complete   history   and   physical   examination   of   the   abdomen,   back,  and  legs.  looking    for  alternative  causes  for  the  back  pain,   2. Consider  plain  x-­‐rays  of  the  lumbosacral  spine  of  those  who  have  suffered   from  severe  pain  and  difficulty  in  bending.   3. Order   and   ESR   on   patients   with   history   of   cancer   or   I/V   drug   abuse   or   sign  and  symptoms  of  underlying  disease.   4. For  point  tenderness  over  a  sacroiliac  joint  with  no  neurologic  findings  to   suggest  nerve  root  compression,  refer  to  neurosurgery  team.   5. Advise   injection   Voltran50   mg   +Injection   Dexamethasone   8   mg   both   together  IM.   6. If  there  is  acute  trauma  with  in  one  hour,  advise  inj.  Methylprednisolone.   7. Prescribe      ice  to  the  acutely  injured  area,  20  minutes  /hour  for  first  day.   8. Arrange  appointment  for  neurosurgery  OPD.   9. Teach   them   to   avoid   twisting   and   bending   when   lifting   and   show   them   how   to   lift   with   back   vertical,   using   thigh   muscles   and   holding   heavy   objects  close  to  the  chest  to  avoid  re-­‐  injury.  WHAT  NOT  TO  DO:   a) Don’t  be  eager  to  use  narcotics  pain  medications.   b) Do  not  apply  lumber  traction.     36  
  37. 37. MINOR  HEAD  TRAUMA  A  patient  is  brought  in  the  emergency  department      after  suffering  a  blow  to  the  head,  there  may  or  may  nor  be  laceration,  scalp  hematoma,  headache,  transient  sleeplessness  and  or  nausea  but  there  was  no  loss  of  consciousness  or  amnesia  for   the   injury   or   preceding   events,   seizure.   Neurological   changes   or  disorientation.  WHAT  TO  DO:   1. Take  the  history  and  ascertain  why  the  patient  was  injured.   2. Perform   and   record   physical   examination   of   the   head,   looking   for   signs   of   skull  fracture.   3. Perform  and  record  a  neurological  examination  with  special  attention  to   mental  status,  cranial  nerves  and  deep  tendon  reflex  to  all  four  limbs.   4. If  the  history  or  physical  examination  suggests  there  is  clinical  evidence  of   intracranial  injury  ,  then  call  surgical/neuro  team.   5. Criteria  for  obtaining  CT  Scan  includes   i. Documented  loss  of  consciousness   ii. Amnesia   iii. CSF  leakage  from  nose  or  ear   iv. Blood   behind   the   tympanic   membrane   or   over   the   mastoid  (Battle’s  sign)   v. Stupor   vi. Coma   vii. Any  focal  neurological  sign.     37  
  38. 38. 6. If  there  is  no  clinical  indication  for  CT  Scan  or  skull  x-­‐rays,  explain  to  the   patient   and   concerned   family   and   friends.   Many   patients   expect   x-­‐rays,   but  gladly  forego  them  once  you  explain  they  are  of  little  value.   7. Make  sure  that  family  understood  and  are  given  written  instructions  that     i. Any  abnormal  behavior   ii. Increasing  drowsiness   iii. Difficulty  in  arousing  the  patient   iv. Headache   v. Neck  stiffness.   vi. Vomiting     vii. visual  problem   viii. Weakness   ix. Seizures  are  signals  to  return  to  the  ED.  WHAT  NOT  TO  DO:   a) Do  not  skip  on  the  neurological  examination  or  its  documentation.   b) Do  not  be  reassured  by  negative  skull  films,  which  do  not  rule  out   intracranial  bleeding  or  edema.             38  
  39. 39. MUSCLE  STRAINS  AND  TEARS.  Strains  occur  during  or  after  a  vigorous  over  stretching  of  a  muscle  bundle  that  leads   to   an   insidious   development   of   pain   and   tightness   that   is   worse   with   use  and  better  with  rest.  Tear   of   the   muscle   belly   tend   to   be   partial,   with   sudden   onset   pain   and   partial  loss  of  function.  Often  a  tear  occurs  with  considerable  bleeding  that  can  lead  to  remarkable   hematomas   causing   swelling   at   the   site   and   dissecting   along   tissue  planes  to  create  e  ecchymosis  at  a  distant.  Complete  tears  are  more  likely  in  the  tendinous  part  of  the  muscle,  WHAT  TO  DO:   1. Obtain  a  history  of  mechanism  of  injury.   2. A  complete  tear  of  a  muscle  merits  orthopedic  consultation.   3. For  muscle  strain,  provide  soft  splint,  analgesics  and  instruct  the  patient   to  apply  warm  moist  compresses  for  comfort.   4. For   muscle   tear,   construct   a   loose   splint   to   immobilize   the   injured   part   and  instruct  the  patient  in  rest,  elevation  and  ice.    NAIL  ROOT  DISLOCATION.  The   patient   has   caught   his/her   finger   in   the   car   door,   or   dropped   a   heavy   object,  like   a   cane   of   vegetable   on   a   bare   toe,   with   the   edge   of   the   cane   striking   the   base  of  the  toenail  and  causing  a  painful  deformity.  The  base  of  the  nail  will  be  found  resting  above  the  eponychium  instead  of  its  normal  anatomical  position  beneath.     39